Provider Demographics
NPI:1316009574
Name:JOHNSON, DIANE MARIE (MS, LPC, NCC)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:MISS
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5414 SAVANNAH RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64505-1146
Mailing Address - Country:US
Mailing Address - Phone:816-364-4292
Mailing Address - Fax:816-364-2648
Practice Address - Street 1:5414 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64505-1146
Practice Address - Country:US
Practice Address - Phone:816-364-4292
Practice Address - Fax:816-364-2648
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10001263101OtherCOMMUNITY HEALTH PLAN
MO22330031OtherBLUE CROSS BLUE SHIELD